Claim Specialist Job Description
Claim specialist
provides support with the interpretation and implementation of University policy and procedures in accordance with federal regulations and state statutes related to institutional compliance; prepare and disseminate compliance information.
Claim Specialist Duties & Responsibilities
To write an effective claim specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included claim specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Adheres to international privacy policies, practices and procedures and company standards
Claim ownership for clear liability claims with first party injuries
Responsibility for taking loss facts from the customer and making a liability decision and then settling the claim with the claimant or the other carrier
Enter batch details as per stipulated procedures in the Claims batch log or post log, according to the type of claim
Send and receive claims for translation as per stipulated procedures
Send Claims settlement letters (EOBs) to the claimants according to relevant procedures
Directly investigate each ABI claim through prompt and strategically-appropriate contact with appropriate parties such as policyholders, accounts, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential
Represent the company as a technical resource, attend legal proceedings as needed, act within established professional guidelines applicable laws
Maintain database of all insurance policies and customer contracts on sharepoint and on shared drives
Utilize advanced technical knowledge to audit injury claims (first party, third party and litigation) to ensure compliance and quality standards are met
Claim Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Claim Specialist
List any licenses or certifications required by the position: AHIMA, NFIP, LOMA, CCS, SIP, CA, CPC, AIC, PMP
Education for Claim Specialist
Typically a job would require a certain level of education.
Employers hiring for the claim specialist job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Collage Degree in Education, Business, Computer Technology, Technical, Law, Supervision, Associates, Healthcare, Communication, Management
Skills for Claim Specialist
Desired skills for claim specialist include:
Medical terminology
Procedures
Liability
Laws
Policies
Property damage
Property related issues to handle claims with quality within authority
Statutes and insurance regulations when determining coverage
State compliance regulations and interpretation of state statues
Windows
Desired experience for claim specialist includes:
Demonstrated sound judgment and initiative
Self-directed organizational, attention-to-detail, follow-through, critical thinking, and innovative problem solving skills
Strong time management skills and prioritizing
Utilize advanced technical knowledge to audit property claims (with a focus on property estimating) to ensure compliance and quality standards are met
Issuing payments, sending compliance letters, and other relevant documents
5 years experience in adjudicating Disability and Critical Illness claims
Claim Specialist Examples
1
Claim Specialist Job Description
Job Description Example
Our company is growing rapidly and is looking to fill the role of claim specialist. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claim specialist
- Identifies and investigates claim formatting issues and escalates to applicable department
- File and/or re-file primary and secondary claims
- Perform web research and update patient accounts as necessary
- Identify potential claim issues and escalate to applicable department
- Meet productivity and quality benchmarks as set by the department
- Documents findings and actions taken into the appropriate system
- Escalates claim issues to Team Lead, Manager or department based on the nature of the issue
- Maintains and protects confidentiality with regard to all aspects of patient care information
- Understands and adheres to the Shared Services for Physicians patient balance collection philosophies
- Monitor edits, exception, and response reports to identify and ensure successful claim submission
Qualifications for claim specialist
- Experience in medical or health insurance fields or disability experience is preferred
- Experience in Business Auto Claims preferred with medical or health insurance fields or disability experience
- Perform root cause analysis and create solutions that resolve exceptions at the source, preventing them from reoccurring in the future
- Partner with payer representatives, third-party clearinghouses, or internal customers to resolve claims processing or submission issues
- Identify and communicate claim edit requirements
- Escalate claim submission issues or trends to leadership as needed
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Claim Specialist Job Description
Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of claim specialist. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claim specialist
- Communicate with the members about their claims accurately and effectively under the instructions of the Claims Executive
- Receive all incoming claims through all sources
- Route mail to other offices as necessary
- Update dashboards with the daily count of incoming claims
- Accurately log all incoming claims
- Track priority batches from identified premium providers
- Flag all urgent claim submissions to the Claims Manager / Senior Claims Executive
- Respond to any queries within the remit of their job function.• To resolve any technical issues with the scanning or the post / batch logging of the claims within the boundaries of knowledge and escalate the issues to the Claims Manager / Senior Claims Executive in a proactive manner
- Provide daily and weekly reports/logs as and when required by the Claims Manager / Senior Claims Executive, and ensure logs are updated and maintained regularly
- Check for delayed claims submission from providers as per the contract agreements
Qualifications for claim specialist
- High degree of drive, initiative, and follow through
- Experience in contract management in large complex capital projects and preferable some exposure to Site Construction issues
- Experience in complex negotiations and in arbitration cases
- 1 year of more of claim processing and/or claims adjustments experience
- Microsoft Office proficiency in Outlook, Excel, and Word
- 3-5 years Claim processing experience Preferred
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Claim Specialist Job Description
Job Description Example
Our growing company is looking to fill the role of claim specialist. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claim specialist
- Assigning of payment entity to be used for data entry of the individual batches
- Liaising with the vendors for claims count and payment entity related queries
- To buddy up with lesser experienced staff and participate in training tasks as and when requested by the Claims Manager / Senior Claims Executive
- To promote the best image for the company through professional appearance and behaviours and to maintain the highest level of personal conduct
- Proactively review CFAs for adherence to quality standards and trend analysis
- Apply the Company's claim quality management protocols, Best Practices and metrics to all claims
- Recognize and implement alternate means of resolution
- Apply litigation management through the selection of counsel, evaluation and direction of claim and litigation strategy
- Attend depositions, mediations, arbitrations, pre-trials, trials and all other legal proceedings, as needed
- Appropriately deal with information that is considered personal and confidential
Qualifications for claim specialist
- Experience in an administration role/office environment is preferable
- The individual should also be computer literate and proficient in the use of the Microsoft Office suite
- Evaluate all claims for recovery potential
- Run insurance test claims through electronic software using multiple data resources
- Contact insurance provider and branch to gather additional information or documentation for rejected claims
- Document insurance coverage in the patient profile
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Claim Specialist Job Description
Job Description Example
Our growing company is hiring for a claim specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claim specialist
- Acts as an expert in administration of standalone FMLA leaves and other leaves in adherence to federal, state regulations and company plans
- Analyze, identify and implement strategies to enhance claim management, customer centricity and efficiency
- Audit claim files and monthly call monitoring to identify improvement opportunities
- Supports and guides team members to meet or exceed regulatory and compliance requirements
- Reviews and approves key decisions made by team members
- Motivate team members providing work direction to lower-level staff members
- Negotiates difficult situations between customer and contractors to find optimal solution to problem
- Develops multiple bids per job to insure internal business partners stay within their allotted budget
- Research on damage types, repair processes and costs
- Report to internal stake holders case status and resolution
Qualifications for claim specialist
- 2+ years experience in healthcare reimbursement/collections required
- A high school diploma or equivalent is required with a two year college degreepreferred.strong analytical skills are required
- Excellent verbal and written communication skills are required for corresponding with clients about the disposition of claims
- One year of transportation and claim experience is preferred
- Solid business knowledge of TAM products
- Proficient in use of multiple systems and technology resources
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Claim Specialist Job Description
Job Description Example
Our innovative and growing company is looking for a claim specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claim specialist
- Collection, data quality and maintenance of client´s claims
- Managing customer´s complaints escalated from the Customer Service department
- Delivery performance measurements against the target of identification of non-conformities
- Register and follow-up of non-conformities encountered by 3rd party warehouses
- Understanding of the legal requirements from LSP when handling claims
- Proactive towards the development of more efficient and quality processes related to claim management
- Reporting and coordinating distribution incidents
- Attention to detail is required to capture information, determine benefit amounts, review applications and any policy changes that have occurred during the policy history
- Review claim forms, death certificates and legal documents to determine when claim is eligible for payment
- Adhere to state and company guidelines to ensure our beneficiaries are paid or supplementary contracts are placed in a timely manner
Qualifications for claim specialist
- Ability to read, interpret and explain contracts and TAM plans
- Although experience is preferred it is not essential
- Basic knowledge of excel and work is beneficial
- Looking for a hard-working, enthusiastic and flexible person who wants be a part of a close and professional team
- Strong knowledge/skill in presentation, electronic mail, data entry, plus PC knowledge to include various software packages Word, Excel
- Ability to meet deadlines under pressure, and realize when to escalate an issue